The Emergency Department in the Post SARS era

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The Emergency Department in the Post SARS era

• Peter Cameron
• Previously
• Prince of Wales Hospital
• Chinese University of Hong Kong

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Emergency Department First line-The Problem

• Ability of ED to identify Potential high risk
  patients
• SARS demonstrated that non specific features most
  common
• EDs Poorly constructed to manage an Infectious
  Disease Outbreak
• Processes within ED increase risk
• Staff not good at basic ID control procedures
• Balance between high volume service commitments
  and potential risk

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ED as first line

• Communication with hospital
• Communication with community
• Communication with region

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SARS

• It is not Severe
• Or Acute
• Or Respiratory
• At the outset

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Front line experience with SARS

• ICU and Ward healthcare workers more at risk than
  ED
• Cross infection amongst patients was less than
  expected
• Despite high risk environment many HCWs did not
  follow guidelines
• Virtually all hospital infections could have been
  prevented by basic infection control

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Staff getting sicker
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Future Potential Risk

• SARS could come back
• Other infectious disease outbreaks could occur
• Most likely Influenza
• Routine presentations(eg TB,gastro) put
  patients/staff at risk
• Therefore at a staff health and safety level
  action should be taken

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Response

• Engineering
• Patient Processes
• Staff training
• PPE
• Outbreak response

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Engineering

• Avoid crowded EDs
• gt1 m between pts
• Where possible have physical barriers between
  patients
• Separate hand washing for each pt
• Avoid prolonged stay in ED
• Separate toileting
• Washing
• Ventilation negative pressure rooms?
• Adequate sewage system

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Busy ED
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Shut Down By the Plague?

• Emergency closed at PWH
• No elective operations at PWH

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Patient Processes

• Track pt cohorts through different areas
• Eg injury/fever
• Avoid unnecessary pt contact
• Separate work bench areas from pt care areas
• Avoid high risk procedures where possible
• Eg nebulisers/NIVA
• Avoid unnecessary admissions
• Hospitals dangerous places
• Avoid Unnecessary Patient movement b/n areas
• Only necessary Traffic through ED

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Staff Training

• Accredit staff in ID procedures
• Audit infection control
• Incorporate into undergraduate training

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Droplet Precautions in every ward
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Personal Protective equipment

• Simplicity
• Long term practicality
• Masks/handwashing easy
• N95 vs surgical masks?
• Space suits expensive and impractical
• Identify particularly high risk groups
• Eg contact history/atypical/severe presentation
  or procedures eg ETT
• ?triage to different area/negative pressure

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Outbreak response

• Local
• Regional
• National/International

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Local

• Identification of Outbreak
• Background monitoring
• Awareness through health department
• Unusual case
• High Index of Suspicion
• Command team
• Communication
• Contact tracing

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Predetermined Communication Protocol

• Meetings of Senior staff
• Departmental meeting
• Staff Forum
• Email
• Web site
• Rumours are always worse than reality

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Local

• Screening in community hospital
• Best site?
• ED
• OPD
• Health Department
• Facilities
• XRAY
• CT
• PATHOLOGY
• PPE
• VENTILATION
• SPACE

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Local

• Plan for service distribution in outbreak
• Knowledge of resources
• Practice
• Incorporation of plan into normal service

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Regional

• Above issues
• Schools
• Public announcements panic vs ignorance
• Experience suggests that transparency creates
  less panic
• Quarantine
• Restrictions on movement cause panic
• May lead to opposite effects to what you want
• Effectiveness of home quarantine?
• Is it right to house those with disease and
  without together?

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National/International

• Effect on economy/business/Travel
• Vs International responsibilities
• Resources diverted to maintain infrastructure/trai
  ning for possible outbreak vs provide routine
  services

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Every Hospital Should Have

• A disaster Plan
• An infectious disease outbreak plan
• Regular review/audit and practice of plan
• Integration with regional hospitals and ambulance
• Disease monitoring and reporting capability

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Unsolved Problems

• Specialised ID hospital takes all?
• At Princess Margaret in HKquickly overwhelmed
• Danger that expertise is concentrated
• Also abrogation of responsibility from non
  specialised hospitals
• Primary triage to right hospital first time
  preferable
• However
• In small numbers processes at ID hospital good
• Allows collaboration b/n experts
• Mixed model may be best

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Unsolved Problems

• Staff Quarantine?
• May lose staff
• Immediate
• Long term
• Alternatives can be almost as bad
• Eg no physical contact etc
• Visitor policy
• Introduce early
• But very hard on pts/relatives

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Unsolved Problems

• Contact Quarantine
• Ideally all isolated
• BUT
• Facilities
• Cross infection
• Deters people from coming forward
• Compromise
• High risk formal quarantine
• Low risk - responsible
• Home with restrictions

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Conclusion

• The biggest gains in risk reduction
• Simple infection control measures
• Simple ED design changes
• Staff training/auditing
• Good ED pt processes
• ie avoid overcrowding etc
• Little evidence for negative pressure/space
  suits/ID hospitals
• This is probably true even for diseases other
  than SARS